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The new engl and journal of drugs Brain Altered mental status Cognitive defects “Megaloblastic madness”: despair, Optic atrophy, anosmia, loss of style, mania, irritability, paranoia, delusions, lability glossitis Spinal wire Myelopathy Spongy degeneration Abnormalities in infants and youngsters Developmental delay or regression, permanent incapacity Does not smile Feeding difficulties Hypotonia, lethargy, coma Hyperirritability, convulsions, tremors, Paresthesias myoclonus Loss of proprioception: vibration, Microcephaly place, ataxic gait, limb weak spot; spasticity (hyperreflexia); positive Choreoathetoid actions Romberg sign; Lhermitte’s signal; segmental cutaneous sensory level Autonomic nervous system Postural hypotension Infertility Incontinence Impotence Peripheral nervous system Peripheral blood Cutaneous sensory loss Macrocytic red cells, macroovalocytes Hyporeflexia Anisocytosis, fragmented varieties Symmetric weak spot Hypersegmented neutrophils, 1% with Paresthesias six lobes or 5% with 5 lobes Leukopenia, attainable immature white cells Bone marrow Thrombocytopenia Hypercellular, elevated erythroid Pancytopenia precursors Elevated lactate dehydrogenase degree Open, immature nuclear chromatin (extremes possible) Dyssynchrony between maturation of Elevated indirect bilirubin and cytoplasm and nuclei aspartate aminotransferase levels Giant bands, metamyelocytes Decreased haptoglobin degree Karyorrhexis, dysplasia Elevated levels of methylmalonic acid, Abnormal results on flow cytometry homocysteine, or each and cytogenetic evaluation 152 n engl j med 368;2 nejm. 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